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Thread: Coding of Chief complaint

  1. #1
    Join Date
    Apr 2007

    Default Coding of Chief complaint

    AAPC: Back to School
    How many coders will code from the chief complaint? I believe it is incorrect, it is not a component of the office visit, but would like others opinion

  2. #2
    Join Date
    Apr 2007
    Olympia, WA


    I asked this question at one of the coding classes I've taken and the answer was, generally not used, however if your provider refers to the info in the CC within the body of their chartnote then OK. IE - within HPI...as noted above in the CC...
    Hope this helps :-)

  3. #3


    Coding from the chief complaint to get a level of e/m? it's a component of 'history' and should always be apart of every encounter... BUT it should not be directly coded from to come up w/ a particular level as there are particular documentation requirements for the category of service (95 & 97 guidelines)

    if you're speaking about icd9 codes - i believe the dx codes should come from the HPI (which of course is a detailed descripion of the chief complaint) and/or the assessment/plan - always follow the icd9 coding guidelines. sometimes in the HPI, you may have signs & symptoms and in the A/P you have a definite diagnosis, which then you are not required to code out the signs/symptoms.

    i hope i explained that well enough
    just my 2 cents worth!!

  4. #4


    Your CC set's the way for the medical necessity though, which of course plays a roll in the final CPT code. Example, if a pt comes in c/o foreign body in eye, the medical necessity to perform a complete exam on all body areas isn't there. So it is in some way yes it lays the ground work.
    adrianne, cpc

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